Challenges in managing HIV and non-communicable diseases and health workers’ perception regarding integrated management of non-communicable diseases during routine HIV care in South Central Uganda: A qualitative study

Background Non-communicable diseases are highly prevalent among adults living with HIV, emphasizing the need for comprehensive healthcare strategies. However, a dearth of knowledge exists regarding the health systems challenges in managing HIV and non-communicable diseases and the perception of health workers regarding the integrated management of non-communicable diseases during routine HIV care in rural Ugandan settings. This study aims to bridge this knowledge gap by exploring the health system challenges in managing HIV and non-communicable diseases and health workers’ perception regarding the integration of non-communicable diseases in routine HIV care in South Central Uganda. Methods In this qualitative study, we collected data from 20 purposively selected key informants from Kalisizo Hospital and Rakai Hospital in South Central Uganda. Data were collected from 15th December 2020 and 14th January 2021. Data were analyzed using a thematic content approach with the help of NVivo 11. Results Of the 20 health workers, 13 were females. In terms of work duration, 9 had worked with people living with HIV for 11–15 years and 9 were nurses. The challenges in managing HIV and non-communicable diseases included difficulty managing adverse events, heavy workload, inadequate communication from specialists to lower cadre health workers, limited financial and human resources, unsupportive clinical guidelines that do not incorporate non-communicable disease management in HIV care and treatment, and inadequate knowledge and skills required to manage non-communicable diseases appropriately. Health workers suggested integrating non-communicable disease management into routine HIV care and suggested the need for training before this integration. Conclusion The integration of non-communicable disease management into routine HIV care presents a promising avenue for easing the burden on health workers handling these conditions. However, achieving successful integration requires not only the training of health workers but also ensuring the availability of sufficient human and financial resources.

Written informed consents were obtained from respondents prior to participation in the study.These consents were written and administered in either Luganda or English.
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Introduction
It is estimated that over 70 million people have been infected with HIV.Furthermore, over 30 million people have died from acquired immunodeficiency syndrome (AIDS) since the 1980s [1].Sub-Saharan Africa contributes to 90% of all people living with HIV (PLHIV) [2].The wide scale-up of antiretroviral therapy (ART) has reduced the impact of the HIV epidemic.However, it has contributed to the non-communicable diseases (NCDs) burden among PLHIV [3].Non-communicable diseases place a huge burden on the healthcare system as they increase healthcare costs [4], [5] and overburden the health workers with the need to manage NCD independent of HIV.Furthermore, they require a lot of consultations and unplanned hospital admissions [6]- [8].
About 6% of Ugandan adults live with HIV [9].Of these, 20% have an NCD [10].Among those with an NCD, adherence to NCD treatment is less than 30% [11], [12].Therefore, integration of NCD management in routine HIV care and treatment could offer an opportunity to improve adherence to treatment.It could further reduce the burden on the health workforce [13].
In Uganda, little is known about the health systems challenges in managing HIV patients with NCDs.
Furthermore, little is known about the perceptions of health workers towards integration of noncommunicable disease management in routine HIV care.This study therefore explored the health systems challenges in managing NCDs among PLHIV.It also explored the perception of health workers towards NCD integration in routine care in south Central Uganda.

Study design:
We conducted a qualitative exploratory study utilizing key informant interviews with health workers.
Setting and population: Kalisizo Hospital is a Ministry of Health (MoH) Hospital located in Kalisizo town, Kyotera district.The Hospital is approximately 30kms from Masaka Regional Referral Hospital.The Hospital provides outpatient and inpatient services including maternal, reproductive, child health, nutritional, HIV, NCD screening and management and general health care.Kalisizo Hospital is the main Hospital for Kyotera district and serves as the referral Hospital for lower-level health facilities within the district.It has a catchment population of approximately 70,000 people [14]- [16].The Hospital has a bed capacity of 120 beds.Over 87% of the population served live in rural areas who majorly depend on agriculture, trading, and fishing.HIV prevalence in Kyotera district is greater than 10% [17].
Rakai Hospital is a MOH Hospital located in the town of Rakai, Rakai district, about 61 kms southwest of Masaka Regional referral Hospital.It is the Main and only Hospital in the district, and it provides inpatient and outpatient services including maternal, reproductive, child health, nutrition, HIV, NCD screening and management and general Healthcare.It is a predominantly a rural facility with a bed capacity of 100 beds [18].Included in the study were health workers who were either working at Kalisizo or Rakai Hospital, had 1 or more years of experience managing PLHIV and consented to participate in the study.

Sample and recruitment :
The sample size for the study was guided by saturation principle and 20 key informant interviews were done.Of the key informants, 12 were selected from Kalisizo Hospital and 8 were selected from Rakai Hospital.Purposive sampling was used to select key informants.

Data collection:
Data were collected from 15 th December 2020 and 14 th January 2021 using a key informant interview guide with standardized open-ended questions.The tool contained questions about the common NCDs among PLHIV, questions on how they are managed, the challenges in their management, what could improve their management and what they thought about integrated management of NCDs in routine HIV care.With the key informant's permission, field notes were taken and were supplemented with audio recordings.All the key informant interviews were conducted in English and lasted 40 to 60 minutes.

Data Analysis.
Data were managed using NVivo software.The thematic content analysis approach, as proposed by Bardin in 1977, was adopted to analyze data.Operationally, all the significant statements in the interviews were open coded (that is, we did not use pre-set codes), and then some clusters of codes were identified as themes.Then, these themes were circumscribed into thematic categories, forming analogical groups, classified, and aggregated according to what was understood about their meanings for the study participants.The interviews were analyzed and coded one by one after carefully reading the transcripts and field notes.This analysis led to saturation of the results, as we had sufficient elements to reach the proposed objective.Finally, the thematic categories and respective themes were examined and discussed with the aim of adopting a comprehensive and interpretive approach of the results.

Characteristics of Key informants
Of the 20 key informants, 13 were females.In terms of work duration, 11 had worked with PLHIV for 11-15 years and 9 were nurses.This is presented in table 1. "Depression is like a sister to HIV at the hospital….Many will become worried to the extent of failing to perform normal duties and on investigation, a diagnosis comes positive for depression" (KI 20).
"Depression is very common here…one in every three clients will experience depressive symptoms at least one a year" (KI 01).
"Generally, mental health concerns are highly prevalent here…We even have clients who have ever attempted suicide…" (KI 15).

Health systems challenges in managing HIV patients with NCDs:
Polypharmacy: Although health workers perceived that most of their patients had low viremia, they noted challenges in coordinating medications, managing adverse events, handling unwanted drug interactions when coordinating HIV management with treatments for NCDs.Dealing with multiple medications and medication interactions were common concerns of health workers: "People living with HIV who have NCDs come to the hospital feeling sad due to multiple medications… Some will even tell you they are done with certain drugs and others say they are tired of taking all drugs…we sometimes become confused how well to handle interaction given that you prescribe these drugs knowing possibilities of interaction and adverse events".(KI 08).
"A patient will come with drug related complaints, and you may end up giving them all your attention and ignoring your other patients….managingdrug interaction and adverse event is burdensome…………".

"Polypharmacy has always challenged us….I don't know if drug manufacturers could think of supplying drugs that can treat multiple non-communicable diseases…this could help to reduce our major hurdle:
Polypharmacy" (KI 20).

Poor communication and limited support from highly specialized physicians:
Additionally, health workers had concerns arising from referrals to other health care providers who do not maintain effective communication and feedback with them.One KI said, "We sometimes refer patients to specialized physicians who sometimes don't communicate effectively with us.They'll keep quiet and only communicate back to us occasionally".(KI 06).
"The specialists communicate to us occasionally whenever we refer patients, and we are sometimes forced to wait for their communication before offering care and treatment to these patients and this makes the treatment process difficult…."(KI 09).

Inadequate resources to manage NCDs:
Inadequate resources also challenge NCD management among PLHIV at the Hospital.Managing NCDs is difficult for practitioners especially when compounded with socioeconomic deprivation and limited budgetary allocation.Managing NCDs is financially costly yet the budget allocated to care, and treatment of these conditions is limited.One KI noted: "Some of these conditions especially hypertension and type 2 diabetes may require primary and secondary care, outpatient visits, and hospital admissions and these strain the Hospital's limited resources".(KI

"Each of these conditions is expensive to manage independently and you can imagine if an individual has multiple conditions". (KI 04).
Another KI stated that: "When compared to their HIV negative counterparts, PLHIV suffer from condition which weaken their immunity and makes them vulnerable to more infections.Some of these conditions require out of pocket expenditure, yet most of these persons are in dire economic state making it difficult to buy medicines that they require to treat these conditions…...they are required to feed well to stay healthy.However, some of these individuals do not have money to buy food required to maintain healthy diet prior to medication and they sometimes come to the facility seeking some support and we are sometimes required to give financial and non-financial support in terms of food making it difficult for us and the patients".(KI 09).

Unsupportive clinical guidelines:
The clinical guidelines focus on management of single conditions, and this hinders NCD management in this vulnerable population.One KI said: In our study, hypertension and mental health concerns were commonly reported by PLHIV who were receiving care at the Hospitals.This is consistent with findings from [19], [20].The possible explanation for the consistency could be because HIV increases self and public stigma which makes PLHIV vulnerable to mental health concerns [21].
Furthermore, health workers reported several challenges in managing HIV patients with NCDs.For instance, polypharmacy and adverse events are common among NCD patients [22], [23].Multiple drug therapy in multiple disease management is a common area of difficulty for both patients and physicians [24], [25].Polypharmacy is common in multiple disease management because guidelines are single disease focused and advise when to start new drugs but seldom when to stop them.The more LTCs (long term conditions) a patient has the more medications they are likely to be prescribed [25].Polypharmacy commonly leads to drug disease and drug-drug interactions [26].
Limited communication from higher level officers to lower-level health workers also emerged as a key theme from our results, and this is consistent with findings from previous studies.For instance, a study on multimorbidity reported that the involvement of several medical specialists, who each emphasize the importance of 'their' 'guideline' and the 'poor communication from specialists and hospitals to the family physician' made coordination and medication hard to maintain.Despite these reservations, the lower cadre workers desired input of specialist [26].Our findings also reported unsupportive clinical guidelines, inadequate resources and inadequate knowledge and skills in incorporating NCD management in routine HIV care as key challenges in managing HIV patients with NCDs and these results are consistent with findings from [6], [7], [27].
Most health workers preferred integrated management of NCDs in routine care and this is consistent with quantitative results from [28].Furthermore, a qualitative study done in Tanzania reported that both health workers and clients preferred integrated management of HIV and NCDs [29].
This study has several strengths for example, this study was conducted by qualified and experienced research assistants with high expertise in data collection and probing skills and this significantly improved the quality data collected.The study was conducted at two facilities and this increased generalizability of findings.

Study Limitations:
This study did not interview District Health officials.We therefore recommend studies involving district health staff.
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The common NCDs among people living with HIV:
101Metabolic and cardiovascular diseases especially diabetes and hypertension were reported to be common 102 among PLHIV.103"Metabolicconditionsarecommonlyreportedamong PLWHIV on care…… Diabetes is less common as104 compared to hypertension……these conditions are common among PLWHIV compared to those who are 105 HIV negative".(KI09).106"Whenyoutakeblood pressures say for 10 people, two to three will have high blood pressure" (KI 02).110Mental health conditions were also reported to be common among PLHIV at Kalisizo Hospital, 111 prominent among others was depression."Inaddition to other mental health conditions, depression is common among our patients…..One of our client was severely depressed after being diagnosed with diabetes and hypertension….she attempted suicide twice, though we were able to offer her psychotherapy and thank God, she's still alive…….manymore have depression" (KI 11).

KI 18). Perceptions towards integrated management of NCDs in routine care:
It may be easier for us to manage HIV alone.However, if physical and mental health conditions are present, we are unable to consult the clinical guidelines on the proper management of these conditions and this affects our work ….".(KI 07).Of the 20 key informants, most (fifteen) recommended integrated management of NCDs in routine care."Personally,I think by integrating non-communicable diseases in routine HIV care, it will reduce our workload….wewill have more time and we will be able to give our clients the kind of care they deserve, and this will improve non-communicable disease management…" (KI 20).
"I don't think integration is what we need.Our budgetary allocation and human resource capacity cannot facilitate it and I don't think we are ready for it yet…" (KI 14)."I am not knowledgeable enough about managing non-communicable diseases and I don't recommend integration" (KI 02).DISCUSSIONWe explored the common non-communicable diseases among PLHIV, the health systems challenges in managing NCDs and the perception of health workers towards integrated management of NCDs during routine HIV care at Kalisizo and Rakai Hospital.Hypertension and mental health conditions especially depression were commonly treated by health workers.The challenges that health workers experienced